Page 77 - Cover Letter and Evaluation for Debbie Workman
P. 77
12/13/2017 Your Medicare Health Plan Details
Preventive care $0 copay
Emergency care/Urgent care Emergency: $80 per visit (always covered)
Urgent care: $30-40 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures: 20%
services/imaging
Lab services: $5
Diagnostic radiology services (e.g., MRI): 20%
Outpatient x-rays: $14
Mental health services $395 for days 1 through 4
$0 for days 5 through 90
Outpatient group therapy visit with a psychiatrist: $30
Outpatient individual therapy visit with a psychiatrist: $40
Outpatient group therapy visit: $30
Outpatient individual therapy visit: $40
Skilled Nursing Facility $0 for days 1 through 20
$160 for days 21 through 55
$0 for days 56 through 100
Rehabilitation services Occupational therapy visit: $40
Physical therapy and speech and language therapy visit: $40
Ambulance $250
Transportation Not covered
Foot care (podiatry services) Foot exams and treatment: $45
Routine foot care: $45
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen): 20% per item
Prosthetics (e.g., braces, artificial limbs): 20% per item
Diabetes supplies: $0 per item
Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy: 20%
Other Part B drugs: 20%
View Less
Benefits Services
Hearing
Hearing exam $10
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H1286&plnid=002&sgmntid=0 2/4
